P317 A…TELL–TALE HEART

Abstract

Abstract We present the clinical case of a 67–year–old male. He was affected by hypertension, hypercholesterolemia; he was heavy smoker. He went to the ED for paresthesias and tremors in the left upper limb, which resolved spontaneously in a few minutes, to which there followed severe thoracic discomfort lasting more than 5 minutes, which resolved during the arrival at the hospital. Upon arrival, the ECG showed ST–segment elevation in leads V4 – V6. POCUS demonstrated akinesia of the apex in its entirety with hypercontractility of the basal segments and the EF was 35%. Blood tests showed an increase in cTI (0.89 ng/ml; vn < 0.16) and CK–MB (57 U/L; vn < 25 U/L). Complete blood count and PCR result in the norm. Coronary angiography showed <50% circumflex artery stenosis, not hemodynamically significant, not treated. Over the next few days the ECG showed marked changes in repolarization, up to T wave inversion; normalized blood tests. During the 3rd day of hospitalization, the patient presented an episode of sensorimotor epileptic seizure in the left upper limb, lasting about 3 minutes, which resolved spontaneously. He underwent a brain CT scan which revealed multiple, edematous brain lesions, probably of a repetitive nature. A whole body CT scan diagnosed lung malignancy. After the oncological evaluation, the patient started chemotherapy. Subsequent follow–ups documented recovery of apical movement at two months. The patient presented a clinical–instrumental picture compatible with the diagnosis of MINOCA. In particular, the echocardiography was suggestive of takotsubo syndrome (TTS). TTS affects 1–2% of patients presenting to ED with ACS and positive troponins or suspected STEMI. It mostly affects women and elderly patients. The exact pathophysiology of TTS is still unknown, but there are numerous determining factors, such as physical and/or emotional stress, that are responsible for sharp increases in levels of circulating catecholamines. Also neurological pathologies, such as ischemic and above all haemorrhagic stroke are implicated. Recent evidence suggests that about one in six TTS patients also have cancer. In conclusion, we described a case where the first clinical manifestation of a lung metastatic cancer was a SCA. In the TTS there can be a "theory of everything", capable of bringing together the various specialists (emergency physician, cardiologist, pulmonologist, general internist, oncologist, etc.) to reach a single outcome, the patient–care.